Health Department Use of Social Media to Identify Foodborne Illness — Chicago, Illinois, 2013–2014

An estimated 55 million to 105 million persons in the United States experience acute gastroenteritis caused by foodborne illness each year, resulting in costs of $2-$4 billion annually. Many persons do not seek treatment, resulting in underreporting of the actual number of cases and cost of the illnesses. To prevent foodborne illness, local health departments nationwide license and inspect restaurants and track and respond to foodborne illness complaints. New technology might allow health departments to engage with the public to improve foodborne illness surveillance. For example, the New York City Department of Health and Mental Hygiene examined restaurant reviews from an online review website to identify foodborne illness complaints. On March 23, 2013, the Chicago Department of Public Health (CDPH) and its civic partners launched FoodBorne Chicago, a website (https://www.foodbornechicago.org) aimed at improving food safety in Chicago by identifying and responding to complaints on Twitter about possible foodborne illnesses. In 10 months, project staff members responded to 270 Twitter messages (tweets) and provided links to the FoodBorne Chicago complaint form. A total of 193 complaints of possible foodborne illness were submitted through FoodBorne Chicago, and 133 restaurants in the city were inspected. Inspection reports indicated 21 (15.8%) restaurants failed inspection, and 33 (24.8%) passed with conditions indicating critical or serious violations. Eight tweets and 19 complaint forms to FoodBorne Chicago described seeking medical treatment. Collaboration between public health professionals and the public via social media might improve foodborne illness surveillance and response. CDPH is working to disseminate FoodBorne Chicago via freely available open source software.

An estimated 55 million to 105 million persons in the United States experience acute gastroenteritis caused by foodborne illness each year, resulting in costs of $2-$4 billion annually (1). Many persons do not seek treatment, resulting in underreporting of the actual number of cases and cost of the illnesses (2). To prevent foodborne illness, local health departments nationwide license and inspect restaurants (3) and track and respond to foodborne illness complaints. New technology might allow health departments to engage with the public to improve foodborne illness surveillance (4). For example, the New York City Department of Health and Mental Hygiene examined restaurant reviews from an online review website to identify foodborne illness complaints (5). On March 23, 2013, the Chicago Department of Public Health (CDPH) and its civic partners launched FoodBorne Chicago (6), a website (https://www.foodbornechicago.org) aimed at improving food safety in Chicago by identifying and responding to complaints on Twitter about possible foodborne illnesses. In 10 months, project staff members responded to 270 Twitter messages (tweets) and provided links to the FoodBorne Chicago complaint form. A total of 193 complaints of possible foodborne illness were submitted through FoodBorne Chicago, and 133 restaurants in the city were inspected. Inspection reports indicated 21 (15.8%) restaurants failed inspection, and 33 (24.8%) passed with conditions indicating critical or serious violations. Eight tweets and 19 complaint forms to FoodBorne Chicago described seeking medical treatment. Collaboration between public health professionals and the public via social media might improve foodborne illness surveillance and response. CDPH is working to disseminate FoodBorne Chicago via freely available open source software FoodBorne Chicago tracked Twitter messages using a supervised learning algorithm (7). The algorithm parsed tweets originating from Chicago that included "food poisoning" to identify specific instances of persons with complaints of foodborne illness. The geographic boundaries used by the algorithm also included some neighboring Chicago suburbs. However, follow-up inspections were conducted only at restaurant locations within the city limits. Tweets identified by the algorithm were reviewed by project staff members for indications of foodborne illness (e.g., stomach cramps, diarrhea, or vomiting) from food prepared outside the home. Project staff members provided feedback on whether each tweet fit the criteria, enabling the tweet identification algorithm to learn and become more effective over time.
For tweets meeting the criteria, project staff members used Twitter to reply. For example, Tweet: "Guess who's got food poisoning? This girl!" Reply: "That doesn't sound good. Help us prevent this and report where you ate here (link to Foodborne Chicago and a web form to report the illness)." The information in submitted forms went directly into the Chicago 311 system that handles all requests for nonemergency city services. Descriptive statistics were used to evaluate FoodBorne Chicago over its first 10 months of use and to compare the results of complaint-based health inspections of food establishments resulting from FoodBorne Chicago use with health inspections of food establishments based on complaints not submitted through FoodBorne Chicago. The comparisons did not include reinspections or routine inspections not based on a complaint.
During March 2013-January 2014, FoodBorne Chicago identified 2,241 "food poisoning" tweets originating from Chicago and neighboring suburbs. From these, project staff members identified 270 tweets describing specific instances of persons with complaints of foodborne illness. Eight of the 270 tweets (3.0%) mentioned a visit to a doctor or an emergency department. A total of 193 complaints of food poisoning were submitted through the FoodBorne Chicago web form. However, project staff members were not able to track how many of the 193 came from persons led to the form via Twitter and how many came from persons who visited the FoodBorne Chicago site on their own.
Of the 193 FoodBorne Chicago complaints, 19 (9.8%) persons indicated they sought medical care. The complaints identified 179 Chicago restaurant locations; at 133 (74.3%) locations, CDPH inspectors conducted unannounced health inspections. These 133 inspections amounted to 6.9% of the 1,941 health inspections of food establishments prompted by complaints during the study period. Of the 133 FoodBorne Chicago-prompted health inspections, 122 (91.7%) inspection reports identified at least one health violation, compared with 91.8% of inspection reports following complaints filed outside of FoodBorne Chicago during the same period.
Of the 133 FoodBorne Chicago-prompted health inspections 27 (20.3%) identified at least one critical violation, compared with 16.4% of the 1,808 inspections not prompted by FoodBorne Chicago. Critical violations indicate an "immediate health hazard" resulting in a high risk for foodborne illness. Critical violations must be fixed while the inspector is present or the restaurant fails inspection, has its license suspended, and is closed.* Twenty-nine restaurants (21.8%) reported via FoodBorne Chicago had at least one serious violation compared with 27.8% of restaurants not reported via FoodBorne Chicago. Serious violations indicate a "potential health hazard" that must be corrected within a timeframe determined by the health inspector, typically 5 days. If the serious violation is not fixed on re-inspection, the license is suspended, and the business is closed. Overall, at least one critical or serious violation was found in 37.6% of inspections prompted by FoodBorne Chicago and 37.2% of inspections from other complaints during the same period.
Some differences were noted in the distribution of specific violations between FoodBorne Chicago inspections and other complaint inspections. For example, 13.5% of FoodBorne Chicago inspections resulted in (critical) violation 3 (i.e., food not stored at appropriate temperatures), compared with 8.2% of other complaint inspections (Table). In addition, 14.3% of other complaint inspections reported (serious) violation 18 (i.e., food not protected from contamination), compared with 6% of FoodBorne inspections.
A total of 21 (15.8%) of the 133 restaurants reported through FoodBorne Chicago failed inspection and were closed; an additional 33 restaurants (24.8%) passed with conditions, indicating that serious or critical violations were identified and corrected during inspection or within a specified timeframe. Of the inspected restaurants with complaints not reported through FoodBorne Chicago, 25.8% failed and 14.2% passed with conditions. During the study period, among all restaurants inspected, FoodBorne Chicago-prompted inspections accounted for 4.3% of failed inspections and 11.4% of pass with conditions inspections.

Discussion
Foodborne illness is a serious and underreported public health problem with high health and financial costs. Emerging evidence on the effectiveness of social media for foodborne illness surveillance suggests mining tweets and restaurant reviews might aid in identifying and taking action on localized foodborne illness  Critical violations V1 All food shall be from sources approved by health authorities and safe for human consumption. Shellfish shall be obtained from an approved source and kept in their original package until sold. Molluscan shell stock shall be obtained in containers bearing legible source identification tags or labels.

V2
All food establishments that prepare, sell, or store hot food shall have adequate hot food storage facilities. All food establishments that display, prepare, or store potentially hazardous food shall have adequate refrigerated food storage facilities. 10 (7.5) 77 (4.3)

V3
All hot food shall be stored at a temperature of 140°F (60°C) or higher. All cold food shall be stored at a temperature of 40°F (4°C) or less.

V4
All food shall be protected from contamination and the elements, and so shall all food equipment, containers, utensils, food contact surfaces and devices, and vehicles.

V5
No person affected with or carrying any disease in a communicable form or afflicted with boils, infected wounds, sores, acute respiratory infection, or intestinal disorder shall work in any area of a food establishment in any capacity where there is a likelihood of that person contaminating food or food contact surfaces. complaints that would otherwise go unreported (5,8,9). Using a new surveillance and response strategy, the CDPH identified and responded to 270 tweets about foodborne illness over 10 months in the Chicago area; 193 Chicago FoodBorne forms reporting foodborne illness were filed during this period. The majority of the 193 forms did not indicate that medical treatment was sought and so would likely not have been included in the usual surveillance numbers nor prompted inspections by the health department. Twenty-one of the reported restaurants failed inspection and were closed; 33 additional restaurants passed with conditions. Rates of critical and serious violations and failing inspections prompted by FoodBorne Chicago complaints were similar to those from inspections in response to other complaints during the same period. The findings in this report are subject to at least two limitations. First, the Twitter application programming interface does not allow precise geographic filtering, and FoodBorne Chicago only used the keyword "food poisoning" to identify tweets. Second, it was not possible to determine how many of the 193 web form complaints were from persons directed to the form via Twitter. Project staff members were able to link 30 tweets directly to a corresponding complaint when report submitters clicked on the link in the "reply tweet" to access and complete the form. However, the number of persons who tweeted, did not click the link, and later accessed the Foodborne Chicago web form is unknown. CDPH food inspectors and supervisors initially were concerned that use of Twitter would overburden them with increased inspections. However, by understanding the process better and seeing the success in finding violations, CDPH staff members have become supportive of obtaining potential foodborne illness information via Twitter.
CDPH and its partners are actively working to improve and disseminate the FoodBorne Chicago program. In an effort to increase the effectiveness of staff replies to complaints via Twitter, CDPH held four focus groups and plans an online survey. In addition, CDPH is currently working with the Boston Public Health Commission and the New York City Department of Health and Mental Hygiene to adapt FoodBorne Chicago for use in those two cities. FoodBorne Chicago also is available as open-source software on GitHub, an online host for sharing computer code with the public or a private audience. † † Additional information is available at https://github.com/smartchicago/foodborne.

What is already known on this topic?
Foodborne illness is a serious and underreported public health problem with high health and financial costs. Local health departments nationwide license and inspect restaurants to prevent foodborne illness and track and respond to foodborne illness complaints. Emerging evidence on the effectiveness of social media for foodborne illness surveillance suggests mining tweets and restaurant reviews might aid in identifying and taking timely action on sources of foodborne illness that would otherwise go unreported.

What is added by this report?
A new open-source surveillance and response tool was used to identify and respond to tweets about foodborne illness in Chicago. Over a 10-month period, the tool identified 133 Chicago-area restaurants that were subsequently inspected. Of these, 21 (15.8%) failed inspection, and 33 (24.8%) passed with conditions.
What are the implications for public health practice?
New technology applied to widely used social media platforms might allow health departments to engage the public to improve foodborne illness surveillance.
Reducing consumption of calories from added sugars is a recommendation of the 2010 Dietary Guidelines for Americans* and an objective of Healthy People 2020. † Sugar-sweetened beverages (SSB) are major sources of added sugars in the diets of U.S. residents (1). Daily SSB consumption is associated with obesity and other chronic health conditions, including diabetes and cardiovascular disease (2). U.S. adults consumed an estimated average of 151 kcal/day of SSB during 2009-2010, with regular (i.e., nondiet) soda and fruit drinks representing the leading sources of SSB energy intake (3,4). However, there is limited information on state-specific prevalence of SSB consumption. To assess regular soda and fruit drink consumption among adults in 18 states, CDC analyzed data from the 2012 Behavioral Risk Factor Surveillance System (BRFSS). Among the 18 states surveyed, 26.3% of adults consumed regular soda or fruit drinks or both ≥1 times daily. By state, the prevalence ranged from 20.4% to 41.4%. Overall, consumption of regular soda or fruit drinks was most common among persons aged 18-34 years (24.5% for regular soda and 16.6% for fruit drinks), men (21.0% and 12.3%), non-Hispanic blacks (20.9% and 21.9%), and Hispanics (22.6% and 18.5%). Persons who want to reduce added sugars in their diets can decrease their consumption of foods high in added sugars such as candy, certain dairy and grain desserts, sweetened cereals, regular soda, fruit drinks, sweetened tea and coffee drinks, and other SSBs. States and health departments can collaborate with worksites and other community venues to increase access to water and other healthful beverages. § BRFSS is an annual, state-based, random-digit-dialed landline and cell phone survey of U.S. adults (aged ≥18 years) that assesses the prevalence of preventive health practices and risk factors for chronic diseases and other conditions. ¶ It uses a complex, multistage cluster sampling design to select a sample representing the civilian noninstitutionalized U.S. adult population in the 50 states, District of Columbia, and three U.S. territories. Weighting is used to adjust for nonresponse, noncoverage, and differences in probably of selection. The median response rate for the 18 states included in this report was 46.2% (range = 27.7%-60.4%).** In 2012, BRFSS included an optional module with questions about SSB consumption: "During the past 30 days, how often did you drink regular soda or pop that contains sugar? Do not include diet soda or diet pop." and "During the past 30 days, how often did you drink sweetened fruit drinks, such as Kool-Aid, cranberry juice cocktail, and lemonade? Include fruit drinks you made at home and added sugar to." Respondents could report monthly, weekly, or daily consumption. All responses were subsequently converted to daily consumption. Daily intake of regular soda, fruit drinks, or both was calculated by summing the daily frequencies for regular soda and fruit drinks. Responses were categorized as none, <1 time/day, and ≥1 times/day. A total of 115,291 adults from the 18 states that offered the module responded to the SSB questions. A total of 1,900 respondents with missing responses to either the regular soda or fruit drink questions were excluded, leaving an analytic sample of 113,391 adults. Chi-square tests were used to determine whether regular soda and fruit drink consumption differed by age group, sex, and race/ethnicity for each state, with p<0.05 as the criterion for statistical significance. Estimates were not reported if a sample size was <50 or the relative standard error was ≥30%.
In most states, fruit drink consumption ≥1 times daily was most common among persons aged 18-34 years, non-Hispanic

Discussion
In 2012, about one in four adults reported consuming regular soda, fruit drinks, or both ≥1 times daily in the 18 states surveyed. The states with the highest prevalence of daily consumption of regular soda, fruit drinks, or both were Mississippi and Tennessee. Further, daily regular soda and fruit drink consumption was most common among those aged 18-34 years, men, non-Hispanic blacks, and Hispanics. Reducing SSB consumption as part of a healthy lifestyle might help with weight management and reduce the risk for chronic diseases among U.S. adults. Persons who want to reduce their daily added sugar intake can consider replacing their consumption of SSB with healthier drinking options (e.g., water, unsweetened tea, and fat-free milk).
These data from respondents in the 18 states that administered the optional SSB module as part of BRFSS in 2012 indicated that 26.3% of U.S. adults drank regular soda, fruit drinks or both daily. In contrast, data from the National Health and Nutrition Examination Survey (NHANES) indicated that the prevalence of daily SSB consumption rates are generally higher than BRFSS response rates † † ; and 5) the NHANES data were collected 4-5 years before the BRFSS data; regular soda and fruit drink consumption among adults aged ≥20 years has been decreasing nationally over the last decade (3,4). The reasons for higher SSB consumption in certain states (e.g., Mississippi and Tennessee) are unclear. It could result from differences in the food environment and beverage marketing. For example, Other, non-Hispanic supermarkets in the southern region of the United States apportion more advertising space in sales circulars to SSB than do supermarkets in other regions, possibly increasing likelihood of SSB consumption (5). A previous study reported that the diet quality of adults in the lower Mississippi Delta, assessed by the Healthy Eating Index, was lower than other areas of the United States (6). This difference could be attributed to lower socioeconomic status, cultural factors, and food availability and accessibility in the area.
Somewhat similar to the present study, other researchers also have reported that younger adults (aged 20-34 years), men, non-Hispanic blacks, and Hispanics are more likely to consume SSB daily (3,4) compared with others. Possible reasons why these groups consume SSB more often might include taste preference, family influence, eating outside of the home, greater exposure to SSB marketing, § § § § Additional information available at http://www.aacorn.org/uploads/files/ AACORNSSBBrief2011.pdf.   Abbreviation: CI = confidence interval. * Weighted percentages might not add to 100% because of rounding. † All values were p<0.05 by chi-square test. § Missing data: 0.5% for age and 2.7% for race/ethnicity. ¶ Differences in fruit drink consumption by sex were not significant. ** Data with sample sizes <50 or relative standard errors ≥30% not reported.
availability and affordability of SSB in particular communities or neighborhoods, and limited knowledge of the caloric content of SSB and their potential contribution to obesity (7,8). For example, the proportion of adults who knew the approximate calorie content of a 24-ounce soda was lowest among non-Hispanic blacks (8). Another explanation for higher SSB consumption could be lower health literacy in some subpopulations, especially among men and blacks (9). Further research could help identify why these disparities exist and how they might be addressed.
The findings in this report are subject to at least five limitations. First, estimates of regular soda and fruit drink consumption were based on self-report, and respondents might not have accurately reported their consumption; therefore, estimates might be either underestimated or overestimated. Second, the consumption frequency of only two types of SSB (regular soda and fruit drinks) was assessed; other types of SSB (e.g., sports and energy drinks, sweetened tea, and coffee drinks) were not included. Third, though it was possible to estimate the prevalence of the frequency of intake as SSB consumption per day, it was not possible to determine the actual amount of SSB consumed. Therefore, the daily calories from SSB could not be determined. Fourth, response bias might have affected the results because survey response rates ranged from 27.6% to 60.4% among states. Finally, these analyses were limited to adults in the 18 states with SSB data available, which limits the generalizability of the findings to the entire U.S. adult population.
SSB such as regular soda and fruit drinks contain added sugars and are sources of calories but have few, if any, essential nutrients (3,4). Because of the potential adverse impact of SSB consumption on diet quality, obesity and other chronic health conditions (2), reducing SSB consumption as part of a healthy lifestyle might help with weight management and the reduction of chronic diseases among U.S. adults. These findings among 18 states suggest that certain segments of the U.S. adult population consume regular soda and fruit drinks more often than others. Persons who want to reduce added sugars in their diet can decrease their consumption of regular soda and fruit drinks, which are the leading sources of SSB (3,4). States and health departments can support persons in these efforts by developing educational campaigns to inform consumers about beverage options and by helping worksites and other community venues increase access to healthful beverages such as water (10).
What is already known on this topic? Sugar-sweetened beverages (SSB) are major sources of added sugars and calories in U.S. diets, and daily SSB consumption has been associated with obesity, diabetes, and cardiovascular disease. During 2009-2010, U.S. adults consumed an average of 151 kcal/day of SSB, with regular soda and fruit drinks representing the leading sources of SSB energy intake.
What is added by this report? This is the first state-specific report on daily SSB intake. Among the 18 participating states, the states with the highest prevalence of consumption of regular soda, fruit drinks, or both were Mississippi and Tennessee. Overall, daily regular soda and fruit drink consumption was most common among those aged 18-34 years, men, non-Hispanic blacks, and Hispanics.
What are the implications for public health practice?
The findings from this study suggest that certain segments of the U.S. adult population consume regular soda and fruit drinks more often than others, which might contribute to weight gain and other chronic conditions. States and health departments can support persons deciding to reduce their regular soda and fruit drink consumption through activities that educate and inform consumers about beverage options and that help worksites and other community venues increase access to healthful beverages.
This report updates the 2013 recommendations by the Advisory Committee on Immunization Practices (ACIP) regarding use of seasonal influenza vaccines (1). Updated information for the 2014-15 influenza season includes 1) antigenic composition of U.S. seasonal influenza vaccines; 2) vaccine dose considerations for children aged 6 months through 8 years; and 3) a preference for the use, when immediately available, of live attenuated influenza vaccine (LAIV) for healthy children aged 2 through 8 years, to be implemented as feasible for the 2014-15 season but not later than the 2015-16 season. Information regarding issues related to influenza vaccination not addressed in this report is available in the 2013 ACIP seasonal influenza recommendations (1).
For recommendations pertaining to use of influenza vaccines in children, ACIP reviewed data on the relative efficacy and safety of LAIV and inactivated influenza vaccines (IIVs). An adapted version of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of the evidence (2). Evidence summary tables and assessment of risk and benefits are available at http://www. cdc.gov/vaccines/acip/recs/grade/table-refs.html. Information in this report reflects discussion during public meetings of ACIP on February 26, 2014, and June 25, 2014. Meeting minutes, information on ACIP membership, and information on conflicts of interest are available at http://www.cdc.gov/vaccines/acip/ meetings/meetings-info.html. Modifications were made during review at CDC to update and clarify wording. Any updates will be posted at http://www.cdc.gov/flu.

Groups Recommended for Vaccination and Timing of Vaccination
Routine annual influenza vaccination is recommended for all persons aged ≥6 months who do not have contraindications. Vaccination optimally should occur before onset of influenza activity in the community. Health care providers should offer vaccination soon after vaccine becomes available (by October, if possible). Vaccination should be offered as long as influenza viruses are circulating. Children aged 6 months through 8 years who require 2 doses (see "Vaccine Dose Considerations for Children Aged 6 Months through 8 Years") should receive their first dose as soon as possible after vaccine becomes available, and the second dose ≥4 weeks later. To avoid missed opportunities for vaccination, providers should offer vaccination during routine health care visits and hospitalizations when vaccine is available.
Antibody levels induced by vaccine decline postvaccination (3)(4)(5)(6). Although a 2008 literature review found no clear evidence of more rapid decline among the elderly (7), a 2010 study noted a statistically significant decline in titers 6 months postvaccination among persons aged ≥65 years (although titers still met European Medicines Agency levels considered adequate for protection) (6). A case-control study conducted in Navarre, Spain, during the 2011-12 season revealed a decline in vaccine effectiveness primarily affecting persons aged ≥65 years (8). Although delaying vaccination might permit greater immunity later in the season, deferral might result in missed opportunities to vaccinate and difficulties in vaccinating a population within a limited time. Vaccination programs should balance maximizing likelihood of persistence of vaccine-induced protection through the season with avoiding missed opportunities to vaccinate or vaccinating after influenza virus circulation begins.

Available Vaccine Products and Indications
Various influenza vaccine products are anticipated to be available during the 2014-15 season (Table). These recommendations apply to all licensed influenza vaccines used within Food and Drug Administration-licensed indications. Differences between ACIP recommendations and labeled indications have been noted (Table).

Vaccine Dose Considerations for Children Aged 6 Months through 8 Years
Children aged 6 months through 8 years require 2 doses of influenza vaccine (administered ≥4 weeks apart) during their first season of vaccination to optimize immune response (10,11). In one study conducted over two seasons during which the influenza A(H1N1) vaccine virus strain did not change but the B antigen did change, unprimed children aged 10 through 24 months who received 1 dose of IIV during the fall of each season had similar responses to the unchanged A(H1N1) virus antigen and to the drifted A(H3N2) virus antigen, compared with children aged 6 through 24 months who received 2 doses of the same IIV during the latter season; however, the first group had significantly lower responses to the B antigen (12). In determining the appropriate number of doses, previous receipt of vaccine containing 2009 influenza A(H1N1) pandemic antigen (included in monovalent pandemic vaccine during 2009-10 and in seasonal influenza vaccines since the 2010-11 season) also should be considered. In addition, because the strains contained in the 2014-15 seasonal influenza vaccines are identical to those contained in the 2013-14 vaccines, only 1 dose is required for any child aged 6 months through 8 years who previously received ≥1 dose of 2013-14 seasonal influenza vaccine.
Two approaches are recommended for determination of the necessary doses for the 2014-15 season; both are acceptable. The first approach (Figure 1) considers only doses of seasonal influenza vaccine received since July 1, 2010. Where adequate vaccination history from before the 2010-11 season is available, the second approach (Figure 1 [footnote]) may be used.

Considerations for the Use of Live Attenuated Influenza Vaccine and Inactivated Influenza Vaccine when Either is Available and Appropriate
Both LAIV and IIV have been demonstrated to be effective in children and adults. In adults, most comparative studies have demonstrated either that LAIV and IIV were of similar efficacy or that IIV was more efficacious (13)(14)(15)(16)(17)(18). However, several studies have demonstrated superior efficacy of LAIV in children. A randomized controlled trial conducted among 7,852 children aged 6-59 months demonstrated a 55% reduction in culture-confirmed influenza among children who received LAIV compared with those who received IIV. LAIV efficacy was higher than that of IIV against both antigenically drifted and well-matched influenza viruses (19). Compared with IIV, LAIV provided 32% increased protection in preventing culture-confirmed influenza in children and adolescents aged 6-17 years with asthma (20) and 52% increased protection in children aged 6-71 months who had previously experienced recurrent respiratory tract infections (21).
ACIP reviewed the evidence pertaining to the relative efficacy of LAIV and IIV for healthy children, and concluded that LAIV is more efficacious than IIV against laboratoryconfirmed influenza among younger children (based on studies including children aged 6 through 71 months), with overall moderate quality of evidence. Risks for harms assessed (including fever, wheezing, and serious adverse events) appear to be similar for LAIV and IIV. Data pertaining to relative efficacy are more limited in older children and teens. There are insufficient data to determine at what age or with how many successive seasons of vaccination the relatively greater efficacy of LAIV diminishes in children aged 6 through 18 years.
For children and adults with chronic medical conditions conferring a higher risk for influenza complications, data on the relative safety and efficacy of LAIV and IIV are limited. A study of LAIV and IIV among children aged 6 through 17 years with asthma noted no significant difference in wheezing events after LAIV (20). Available data are insufficient to determine the level of severity of asthma for which administration of LAIV would be inadvisable.
For  is selected as the upper age limit for this recommendation based on demonstration of superior efficacy of LAIV (ages 2 to 6 years), and for programmatic consistency (8 years is the upper age limit for receipt of 2 doses of influenza vaccine in a previously unvaccinated child). This recommendation should be implemented for the 2014-15 season as feasible, but not later than the 2015-16 season. 3. LAIV should not be used in the following populations: -Persons aged <2 years or >49 years; -Those with contraindications listed in the package insert: ˏ Children aged 2 through 17 years who are receiving aspirin or aspirin-containing products; ˏ Persons who have experienced severe allergic reactions to the vaccine or any of its components, or to a previous dose of any influenza vaccine; -Pregnant women; -Immunosuppressed persons; -Persons with a history of egg allergy; -Children aged 2 through 4 years who have asthma or who have had a wheezing episode noted in the medical record within the past 12 months, or for whom parents report that a health care provider stated that they had wheezing or asthma within the last 12 months (

Influenza Vaccination of Persons with a History of Egg Allergy
With the exceptions of trivalent recombinant influenza vaccine (RIV3 [FluBlok], Protein Sciences) and cell culture-based inactivated influenza vaccine (ccIIV3 [Flucelvax], Novartis), currently available influenza vaccines are prepared by propagation of virus in embryonated chicken eggs. A review of published data (including data on 4,172 patients, 513 of whom were reported to have a history of severe allergic reaction to egg) noted that no occurrences of anaphylaxis were reported, although some milder reactions did occur (23), suggesting that severe allergic reactions to egg-based influenza vaccines are unlikely. On this basis, some guidance recommends that no additional measures are needed when administering influenza vaccine to egg-allergic persons (24). However, occasional cases of anaphylaxis in egg-allergic persons have been reported to the Vaccine Adverse Event Reporting System (VAERS) after administration of influenza vaccine (25,26). In For adults and older children, the recommended site of vaccination is the deltoid muscle. The preferred site for infants and young children is the anterolateral aspect of the thigh. Specific guidance regarding site and needle length for intramuscular administration can be found in ACIP's General Recommendations on Immunization (available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6002a1.htm). § Trivalent inactivated vaccine, intradermal: A 0.1-mL dose contains 9 µg of each vaccine antigen (27 µg total). ** The preferred site is over the deltoid muscle. Fluzone Intradermal is administered using the delivery system included with the vaccine. † † Trivalent inactivated vaccine, high-dose: A 0.5-mL dose contains 60 µg of each vaccine antigen (180 µg total). § § FluMist is shipped refrigerated and stored in the refrigerator at 35°F-46°F (2°C-8°C) after arrival in the vaccination clinic. The dose is 0.2 mL divided equally between each nostril. Health care providers should consult the medical record, when available, to identify children aged 2 through 4 years with asthma or recurrent wheezing that might indicate asthma. In addition, to identify children who might be at greater risk for asthma and possibly at increased risk for wheezing after receiving LAIV, parents or caregivers of children aged 2 through 4 years should be asked, "In the past 12 months, has a health care provider ever told you that your child had wheezing or asthma?" Children whose parents or caregivers answer "yes" to this question and children who have asthma or who had a wheezing episode noted in the medical record within the past 12 months should not receive FluMist. *** Age indication per package insert is ≥5 years; however, ACIP recommends Afluria not be used in children aged 6 months through 8 years because of increased risk for febrile reactions noted in this age group with bioCSL's 2010 Southern Hemisphere IIV3. If no other age-appropriate, licensed inactivated seasonal influenza vaccine is available for a child aged 5 through 8 years who has a medical condition that increases the child's risk for influenza complications, Afluria can be used; however, providers should discuss with the parents or caregivers the benefits and risks of influenza vaccination with Afluria before administering this vaccine. Afluria may be used in persons aged ≥9 years. † † † Information not included in package insert. Estimated to contain <50 femtograms (5x10-8 µg) of total egg protein (of which ovalbumin is a fraction) per 0.5 mL dose of Flucelvax. § § § Available upon request from Sanofi Pasteur (telephone: 1-800-822-2463; e-mail: mis.emails@sanofipasteur.com).
published studies, vaccines containing as much as 0.7 µg/0.5 mL of ovalbumin have been tolerated (27,28); however, a threshold below which no reactions would be expected is not known (27). Among IIVs for which ovalbumin content was disclosed during the 2011-12 through 2013-14 seasons, the reported maximum amounts were ≤1 µg/0.5 mL dose. Ovalbumin is not directly measured for Flucelvax; it is estimated by calculation from the initial content in the reference virus strains to contain less than 5x10-8 µg of total egg protein per 0.5mL dose, of which ovalbumin is a fraction (Novartis, personal communication, 2013). FluBlok is considered egg-free. However, neither Flucelvax nor FluBlok are licensed for use in children aged <18 years. ACIP recommends the following: 1. Persons with a history of egg allergy who have experienced only hives after exposure to egg should receive influenza vaccine. Because relatively few data are available for use of LAIV in this setting, IIV or trivalent recombinant influenza vaccine (RIV3) should be used. RIV3 may be used for persons aged 18 through 49 years who have no other contraindications. However, IIV (egg-or cell-culture based) may also be used, with the following additional safety measures ( Figure 2): -Vaccine should be administered by a health care provider who is familiar with the potential manifestations of egg allergy; and -Vaccine recipients should be observed for ≥30 minutes for signs of a reaction after administration of each vaccine dose. 2. Persons who report having had reactions to egg involving such symptoms as angioedema, respiratory distress, lightheadedness, or recurrent emesis; or who required epinephrine or another emergency medical intervention, may receive RIV3 if they are aged 18 through 49 years and there are no other contraindications. If RIV3 is not available or the recipient is not within the indicated age range, IIV should be administered by a physician with experience in the recognition and management of severe allergic conditions ( Figure 2). 3. Regardless of allergy history, all vaccines should be administered in settings in which personnel and equipment for rapid recognition and treatment of anaphylaxis are available (29). 4. Persons who are able to eat lightly cooked egg (e.g., scrambled egg) without reaction are unlikely to be allergic. Egg-allergic persons might tolerate egg in baked products (e.g., bread or cake). Tolerance to egg-containing foods does not exclude the possibility of egg allergy. Egg allergy can be confirmed by a consistent medical history of adverse reactions to eggs and egg-containing foods, plus skin and/or blood testing for immunoglobulin E directed against egg proteins (30). 5. For persons with no known history of exposure to egg, but who are suspected of being egg-allergic on the basis of previously performed allergy testing, consultation with a physician with expertise in the management of allergic conditions should be obtained before vaccination ( Figure 2). Alternatively, RIV3 may be administered if the recipient is aged 18 through 49 years. 6. A previous severe allergic reaction to influenza vaccine, regardless of the component suspected of being responsible for the reaction, is a contraindication to future receipt of the vaccine.   What is currently recommended?

FIGURE 2. Recommendations regarding influenza vaccination of persons who report allergy to eggs -Advisory Committee on Immunization Practices, United States, 2014-15 influenza season
The Advisory Committee on Immunization Practices (ACIP) recommends that all persons aged ≥6 months without contraindications receive annual vaccinations for protection against seasonal influenza. A number of different seasonal influenza vaccine formulations are available, some of which are licensed for specific age groups or are more appropriate than others for persons with certain medical conditions. On July 10, 2014, CDC was informed by the California Department of Public Health and ORR about four unaccompanied male children aged 14-16 years with respiratory illnesses at Naval Base Ventura County, three of whom were hospitalized with pneumonia. Among the three patients with pneumonia, two were bacteremic with Streptococcus pneumoniae, ultimately determined to be serotype 5, one of whom also had laboratory-confirmed influenza B virus by polymerase chain reaction (PCR). The fourth patient, without pneumonia, had PCR-confirmed influenza A(H1N1)pdm09. Pneumococcal bacteremia is uncommon among U.S. adolescents, particularly serotype 5, with only three such cases identified in the past 10 years by CDC (2). In addition, influenza activity in the United States is typically lowest in the middle of summer, and Ventura County had no reports of an unusual increase in influenza activity in the community at the time.
ORR asked CDC to investigate the scope of this apparent outbreak and implement measures to interrupt transmission.
During July 6-19, 2014, CDC was informed of other clusters of hospitalized children with respiratory disease, increasing the total to 16 cases. The cases were from Naval Base Ventura County (eight cases), Ft. Sill (three), Lackland Air Force Base (two), a standard ORR shelter near Houston, Texas (two), and the Nogales processing center (one). Cases were in persons aged 14-17 years. Diagnoses included laboratory-confirmed pneumococcal pneumonia with laboratory-confirmed influenza (three cases) and without laboratory-confirmed influenza (four cases), influenza pneumonia (one case), and pneumonia with no identified etiology (eight cases). Five patients experienced septic shock requiring intensive care. No case was fatal. All six cases for which pneumococcal isolates were available were identified as serotype 5, a serotype included in 13-valent pneumococcal conjugate vaccine (PCV13) (Prevnar-13, Pfizer). Of the 16 patients identified in this cluster, 11 were tested for influenza viruses; four (36%) were positive (two for influenza A[H1N1]pdm09, one for influenza B, and one for influenza A by rapid test).
Because of the concern that unaccompanied children were at increased risk for influenza and pneumococcal pneumonia in this outbreak setting and the clinically important interaction between influenza and pneumococcal infections (3), CDC recommended that all children residing in temporary or standard ORR shelters receive influenza vaccine and PCV13 in addition to routinely recommended vaccines. Approximately 2,000 children in four affected shelters were vaccinated during July 18-30 with PCV13 and with Food and Drug Administration-approved extended expiration date-specific lots of 2013-14 seasonal influenza vaccine, which includes influenza A(H1N1)pdm09 and influenza B viruses. The shelters reported no serious adverse events.
Although some countries in Central America recommend influenza vaccination for young children, school-aged children generally are not targeted for vaccination (4). Routine annual influenza vaccination is recommended for all persons in the United States aged ≥6 months (5). Because influenza activity was identified among the unaccompanied children, this outbreak underscores the importance of providing routine influenza vaccinations to this population.
PCV13 is routinely given in the United States at age 2-59 months. It is recommended for the older unaccompanied children because of the unexpected number of pneumococcal Notes from the Field pneumonia cases occurring in the context of crowded conditions that likely facilitate spread of respiratory agents and because the risk for serious pneumococcal disease is increased with the circulation of influenza viruses.
Efforts by state and local public health departments were crucial in identifying disease clusters among the children, assisting in investigating the clusters, and supporting immunization activities, highlighting the critical role of state and local health departments working with federal agencies in detecting and responding to outbreaks. Additional information about the ongoing humanitarian and public health response is available at http://emergency.cdc.gov/children/unaccompanied/index.asp. As a result of armed civil conflict in South Sudan that started in mid-December of 2013, an estimated 1.1 million persons were internally displaced, and approximately 400,000 refugees fled South Sudan to neighboring countries (primarily to Ethiopia, Uganda, Sudan, and Kenya). Refugees from South Sudan arriving in Ethiopia are sheltered in three refugee camps located in Gambella region: Leitchuor, Kule, and Tierkidi. The camps were established during January-May 2014 and have estimated refugee populations of 47,000, 51,000, and 50,000, respectively. Reports from health clinics and humanitarian agencies providing assistance to refugees suggested poor nutritional status of arriving refugees and elevated mortality rates. To assess the nutritional status of refugee children aged 6-59 months and mortality rates (crude [all ages] and aged <5 years), the Administration for Refugee and Returnee Affairs (an Ethiopian government aid agency), the United Nations High Commissioner for Refugees, World Food Programme, and United Nations Children's Fund, in collaboration with CDC, conducted cross-sectional population-representative surveys in Leitchuor, Kule, and Tierkidi camps during June-July 2014. Anthropometric measurements in children were taken using standard procedures (1), and nutritional status was classified based on 2006 World Health Organization (WHO) growth standards (2). Hemoglobin was measured using HemoCue Hb 301 (3). Anemia was diagnosed according to WHO thresholds (4). Retrospective mortality rates in Leitchuor and Kule were measured using a household census method.

Malnutrition and Elevated Mortality Among Refugees from South Sudan -Ethiopia
Prevalence of global acute malnutrition among children aged 6-59 months ranged from 25.8% in Leitchuor to 30.3% in Kule, approximately twice the WHO emergency threshold of 15% (5). Prevalence of severe acute malnutrition also was very high, ranging from 5.7% in Leitchuor to 10.0% in Kule (Table). Crude (all ages) and aged <5 years mortality rates substantially exceeded emergency thresholds of 1 and 2 per 10,000 per day, respectively (6), in both Leitchuor and Kule (Table). Anemia prevalence among children aged 6-59 months in all camps exceeded 40%, indicating a problem of high public health significance according to WHO classification (4) ( Table).
These survey results indicate a serious public health emergency among refugees from South Sudan residing in the three camps in Ethiopia. In response to the large influx of refugees into Ethiopia, the Administration for Refugee and Returnee Affairs, the United Nations High Commissioner for Refugees, and other humanitarian agencies established essential health services and nutrition treatment programs coupled with active screening for malnutrition. Blanket supplementary feeding programs targeting young children and pregnant and lactating women were established in all camps. Efforts directed at strengthening outreach activities to detect malnourished children, decentralizing health and nutrition services to improve access, and increasing awareness of the refugee population regarding available blanket feeding programs will be implemented with the goal to improve health and nutrition outcomes and decrease mortality. All registered refugees in the camps are receiving food aid assistance from the World Food Programme, and the planned decentralization of distributions as well as familytargeted distributions (as opposed to group distributions) will aim to improve the overall food security of vulnerable families.    Table 2 listed on pages 703-15 summarizes finalized data, as of June 30, 2014, from the National Notifiable Diseases Surveillance System (NNDSS) for 2013. These data will be published in more detail next year in the Summary of Notifiable Diseases -United States, 2013 (1). Because no cases were reported in the United States during 2013, the following diseases do not appear in these early release tables: anthrax; diphtheria; eastern equine encephalitis, nonneuroinvasive disease; poliovirus infection, nonparalytic; severe acute respiratory syndrome-associated coronavirus disease (SARS-CoV); smallpox; St. Louis encephalitis, nonneuroinvasive disease; western equine encephalitis, neuroinvasive and nonneuroinvasive disease; yellow fever; and viral hemorrhagic fevers. Data on chronic hepatitis B and hepatitis C virus infection (past or present) are not included because they are undergoing data quality review. Data for human immunodeficiency virus (HIV) diagnoses do not appear because CDC is transitioning to a new system for processing national HIV surveillance data, and will be published in the Summary of Notifiable Diseases -United States, 2013.

Final 2013 Reports of Nationally Notifiable Infectious Diseases
Policies for reporting NNDSS data to CDC can vary by disease or reporting jurisdiction depending on case status classification (i.e., confirmed, probable, or suspected). The publication criteria used for the 2013 finalized tables are listed in the "Print Criteria" column of the NNDSS event code list, available at http://wwwn.cdc.gov/nndss/document/ nndss_event_code_list_2013_revised.pdf. In addition, only cases from reporting jurisdictions where the nationally notifiable disease is reportable are published. The NNDSS website is updated annually to include the latest national surveillance case definitions approved by the Council of State and Territorial Epidemiologists for classifying and enumerating cases of nationally notifiable infectious diseases.
Population estimates are from the National Center for Health Statistics postcensal estimates of the resident population of the United States for July 1, 2010-July 1, 2012, by year, county, single year of age (0 to ≥85 years), bridged-race (white, black or African American, American Indian or Alaska Native, Asian or Pacific Islander), Hispanic ethnicity (not Hispanic or Latino, Hispanic or Latino), and sex (vintage 2012), prepared under a collaborative arrangement with the U.S. Census Bureau. Population estimates for states are available at http:// www.cdc.gov/nchs/nvss/bridged_race/data_documentation. htm#vintage2012. Population estimates for territories are 2012 estimates from the U.S. Census Bureau (2).